Monday Musings

On September 28, 2015, CMS made available the 2014 Supplemental Quality and Resource Use Reports (QRURs) to every medical group practice and solo practitioner nationwide. Providers are identified in the Supplemental QRURs by their Taxpayer Identification Number (TIN). The report provides information to providers on the management of their Medicare fee-for-service (FFS) patients based on episodes of care (“episodes”). An “episode” is a resource use measure that includes the set of services provided to treat, manage, diagnose, and follow-up on a clinical condition or treatment. The 2014 Supplemental QRURs are for “informational purposes” only. I think I should probably say this a different way. Outpatient payment is going to start looking like in-patient Diagnosis Related Groups (DRGs). We are just beginning to enter the world of true “bundled payments” in which providers will share a fixed amount of money for the entire “episode” of care. Get used to seeing that word.

Authorized representatives of practitioners can access the 2014 Supplemental QRURs on the CMS Enterprise Portal using an Enterprise Identify Data Management (EIDM) account with the correct role. Only TINs with at least one attributed episode will receive a full 2014 Supplemental QRUR.

I should point out that the following diagnoses are considered “Major Episode Types.”

  • Cellulitis in Diabetics
  • Cellulitis in Patients with a Wound, Non-Diabetic

Patients that are more complex have their episode costs “adjusted downward” using a risk adjustment. If a provider’s average risk-adjusted costs are lower than its non-risk-adjusted costs, then the providers’  patient population is more complex than average. The complexity of the patient population is shown as the beneficiary risk score.

A beneficiary’s risk score percentile is calculated by comparing the beneficiary’s predicted cost (as calculated by the risk adjustment model) to the distribution of predicted costs for all episodes of the same subtype nationally. A higher risk score percentile indicates that, based on the patient’s risk factors, the patient was predicted to have relatively high health care costs for the episode compared to other episodes of the same subtype nationally.

I am thinking that we ought to take a look at this to see what are the beneficiary risk scores for those non-diabetic patients who have wounds. Here’s the link so you can try to check it out. However, now you understand why we need a risk scoring system for wound care like the Wound Healing Index I discussed last week.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Episode-Costs-and-Medicare-Episode-Grouper.html


Caroline Fife, MD

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